Basic Information
| Provider Information | |||||||||
| NPI: | 1538298989 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GALLUP INDIAN MED CENTER PHARMACY | ||||||||
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| OtherOrganizationName: | GALLUP INDIAN MED CENTER PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 31001-0650 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911100650 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 516 E NIZHONI BLVD | ||||||||
| Address2: | |||||||||
| City: | GALLUP | ||||||||
| State: | NM | ||||||||
| PostalCode: | 873015748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057221185 | ||||||||
| FaxNumber: | 5057221554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2007 | ||||||||
| LastUpdateDate: | 01/23/2015 | ||||||||
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| AuthorizedOfficialLastName: | CUMMINGS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHARMACY PROGRAM SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4059516086 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHARMD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332800000X | Y | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 67566 | 05 | NM | MEDICAID | 2058596 | 01 | PK | OTHER |